Lean or Toyota Production System (TPS) is responsible for revolutionizing the auto industry by creating highly reliable and safe cars and trucks. In this course healthcare providers, administrators, engineers, and healthcare professional students will be taught how to apply the principles and tools of Lean to health care. They will learn how to identify and remove of waste, design standardized work, apply 5S, map Value streams, create process maps, conduct rapid improvement events (RIEs), level workflow, use A3 forms and Paredo charts, apply error proofing, and create effective visual controls. The instructional videos minimize Lean technical language, and include patient cases to make the lessons more appealing to students in healthcare. Acknowledging that patients are very different from cars we have carefully adapted Lean to health care and call our system: Patient-centered Healthcare Delivery System (PHDS). The name and abbreviation emphasize two key principles taught in our course: 1. Just like PhDs the scientific method must be continually applied when creating plans to improve our systems of care. 2. All improvements must be made looking through the eyes of patients. Armed with this new knowledge students will be able to design and implement sustainable healthcare delivery system improvements.

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From the lesson

Standardized Work and Preparing for Value Stream Mapping

Standardized work is an absolute necessity for improvement. Without standardized work there can be no improvement. This is one of the most difficult concepts to relay to those on the front lines particularly physicians, who call this "cookbook medicine". In this module the philosophy behind creating standardized work is reviewed, and the importance of everyone on the front line participating in creating and continually modifying standardized work emphasized. You will be introduced to tools that will help you to effectively design standardized work: the spaghetti diagram and the Time Observation Sheet. Lead Time, Cycle Time and Takt Time will be defined. You will learn how time the individual steps of a work process. You will also learn how to use a percentage load chart to calculate how many workers are required to meet production demand.

Taught By

Frederick S. Southwick, MD

Professor

Transcript

In this video we're going to discuss Standardized Work Part 3. In the last video we described how to draw a spaghetti diagram. Next, to create effective standardized work, we must capture the time related to each step in a process. And for this, we use a time observation sheet. Time is one thing that we can never get back. When discussing any work process, this is a precious commodity. Knowing the time a process takes allows the observer to quickly asses the efficiency of the process. Is it improving the ability to meet customer demand? We'll talk about TAKT time and can ensure that the new standards are being maintained. Before analyzing time, it is important to understand three key time intervals. First is lead time. Lead time begins when the request is made and ends when the product or service is delivered to the customer. As an example, let's look at the filling of a prescription. Lead time begins when the doctor writes the prescription for a medication and hands it to the patient. The patient then takes the medication to the pharmacist and the pharmacist fills the prescription. Lead time ends when the pharmacist delivers the medication to the patient and the patient has paid for the medication. The graphic of lead time depicted in the upper of the two graphic figures at the bottom of this slide clearly shows each of those intervals. Cycle time is a shorter interval and is defined as the time required for one operator to complete a single cycle of work. In our example, one cycle in the lead time is the time required for the pharmacist to fill a single prescription. The bottom graphic on this slide shows the multiple cycles of work that are components of lead time in our example. When it comes to meeting demand, the most important time interval, is takt time. This German word originally referred to the time intervals in a musical score and are often measured using a metronome shown in the middle of this slide. When talking about quality and efficiency, takt time is work time divided by demand. As an example, let's return to our pharmacists. On an average day the pharmacist needs to fill 300 prescriptions. The pharmacy opens at 8 and closes at 8 PM, 12 hours. The pharmacist takes takes two one-half hour breaks during that period. Therefore, he or she works for 11 hours or 660 minutes. Takt time equals 660 minutes, the work hours, divided by the demand, 300. Which is 2.2 minutes per prescription, or 22 minutes per ten prescriptions. If the cycle time for filling each prescription equals the takt time, then customer demand is met. If the cycle time is longer than takt time, then the pharmacist will not be able to fill all the prescriptions for the day. The graphic at the bottom of the slide depicts the cycle time intervals for filling ten prescriptions during the day. As you can see, the total time to fill the 300 prescriptions was under the 660 minutes, and the average cycle time equaled the takt time. When talking about efficiency of a process, there are three legs to the stool, standardized work, the expected performance time, the standardized work in progress, the actual performance times, and the takt time. Now let's fill out the time intervals for our time observation sheet. We know that our nurse, Wendy, has 60 minutes to complete her administration of morning medications. She is managing five patients, therefore the takt time for medication administration for one patient will be 60 divided by 5, or 12 minutes per patient. Now that we have calculated this value and have a spaghetti map defining the specific steps, we can begin our timing. Timing is usually performed using a digital stopwatch, and I used my smartphone. I kept the stop watch running and simply wrote down the values as Wendy completed each step. Here each time reading has been typed in next to the specific step. Here is what the times look like on a digital stopwatch. Because most stopwatch indicates the minutes and seconds, these values need to be converted to total seconds. This is done by multiplying the minutes times 60 and adding the residual seconds. Therefore, the middle reading indicates 3 times 60 or 180 seconds plus 0.75 seconds. The left hand reading of 30.15 is subtracted from this value and equals 150.6 seconds. The far right stopwatch reads 4 minutes and 24.8 seconds, and subtracting the middle reading of 3 minutes, 0.75 seconds equals 1 minute, 24.05 seconds or 84.05 seconds. Using this method, the time intervals have been calculated in red on our time observation chart. If you have access to an Excel spreadsheet, you can insert formulas to automatically calculate these intervals. Totalling these intervals, the cycle time to complete the administration of medications for each patient can be calculated. And they were 580 seconds and 675 seconds. Both of these values are below the takt time of 12 minutes, or 720 seconds. In a fully completed time observation sheet, we will need to time these processes between six and ten times, or until we have fully captured the variations in the cycle times. Then on the far right hand column you should record the mode, the time interval that is most frequently recorded. We will show these values in our next video. The average cycle time was 627.5 seconds and is below the the takt time of 720 seconds. The cycle time is less than the takt time, indicating the process is healthy, and that nurse Wendy can meet the demand. As you can see, the time observation sheet provides great insight into the efficiency of any process. Shouldn't we be using time observation analysis to examine every process in healthcare? Thank you.

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